V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K
VA PROSTHETICS: STATUS AND ADVANCES By J.R. Wilson
n ANCIENT TEXTS – POETRY, HEROIC TALES, HISTORIES – make reference to prosthetic limbs dating back as far as 1500 B.C., although the oldest physical evidence is an artificial leg dated at around 300 B.C. Unearthed at Capua, Italy, in 1858, the bronze and iron device, with a wooden core, appears to have been used after a below-the-knee amputation. For the next 1,500 years, little progress was made and prosthetics primarily were cosmetic in nature, aside from those designed to help a horse-mounted knight hold a sword or lance. The only “advances” were the development of the peg leg and hook hand during the “Dark Ages” (476 B.C. to 1000 B.C.). The Renaissance (14th-17th centuries) saw a renewed emphasis, based on resurrected Greek and Roman medical texts, to fit amputees with more functional prosthetic legs and hands, most made of iron, steel, copper, and wood. Increased functionality and lighter, more adaptable materials led to the first real advances during the 16th century. The next three centuries saw incremental improvements in articulation, materials, and functionality, but artificial limbs essentially remained little more than “placeholders” for the amputated limbs. It was not until post-World War II military amputees began demanding greater functionality that researchers again improved the weight and durability of prosthetics and, with the development of transistors and microprocessors, began the modern evolution of technologically advanced components and systems. While significant advances were made in both design and functionality from 1950 through the post-Desert Storm era of the 1990s, all of the factors for a “perfect storm” in prosthetics – from smaller, faster electronics to advanced new lightweight materials to high demand to strong public support – came together at the turn of the century and the beginning of America’s longest war in Southwest Asia. Improved, ubiquitous body and vehicle armor, universal basic medic training for all warfighters, medics trained to EMT levels, and the presence of surgical teams on the front lines made Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) the lowest killed in action (KIA) conflicts in history. But they also led to more amputations and more major loss of limb functionality than at any time since the U.S. Civil War. The Department of Veterans Affairs (VA), the Department of Defense (DOD), and civilian academic and medical research
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facilities all are involved in – and cooperating with each other on – the constant advancement in prosthetics, especially lower limbs, arms, and hands, the latter being by far the most difficult. Prosthetic legs have advanced to the point where some wounded warfighters, told advanced battlefield care has saved their legs – but with only 80 to 90 percent of the functionality they originally had – have asked DOD or VA surgeons to amputate and give them the latest prosthetic leg, which may offer more than 100 percent of a natural leg’s functionality. Even so, artificial legs still are not perfect, with different people experiencing different levels of pain and difficulty adapting to them. Although the number of U.S. warfighters now deployed to Southwest Asia is only a fraction of those there at the peak of the war, interest in further prosthetic technology development and funding for it has remained relatively stable, as has the pace of research, development, test, and evaluation (RDT&E). “Some areas are moving faster than others at different points in the development pipeline,” according to Brian Schulz, PhD, scientific program manager, VA Office of Research and Development. “Multigrasp hands have come a long way, microprocesser knees and ankles have made advances. Most [of those advances] have been on the inside [of the prosthesis], such as neural interfaces and a lot of surgical techniques that show immense promise for the future. “It’s more a steady process of small advances than a big leap. There are some things on the cusp, such as modular implantable neural prosthetic systems that interface the nerves with the prosthetic limb. That doesn’t have full FDA [Food and Drug Administration] approval yet, but once it and others are approved, they will come together in the future to enable much more capability.” The level of funding and research, combined with advances in other technologies that are applicable to improving some part of prosthetic development, such as smaller, faster microprocessers, also have led researchers to take another look at ideas previously shelved because all of the necessary technologies were not there to support them. “A fair amount of funding has gone into trying to improve the socket interface due to the discomfort and skin issues prosthetic users experience. Despite a lot of effort and some incremental advances, I don’t think we’ve really solved the
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